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Testicular Cancer > Seminoma > Flashcards

Seminoma Flashcards

1
Q

RT Dose to for Stage I

A

20 Gy at 2 Gy/fx

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2
Q

DDx for Testicular Mass

A 
Hydrocele 
Orchidis 
Epididymitis
Lymphoma
Torsion 
Seminoma
Nonseminoma
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3
Q

Contraindications to RT

A

IBD
Horseshoe
Prior RT

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4
Q

Elements on History to Ask About

A 
Cryptochidism
Prior inguinal/scrotal surgery 
Prior RT 
Horseshoe kidney
IBD
Testicular mass: pain? duration?
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5
Q

Work up Labs, Imaging, counseling?

A

Test. US bilaterally

After Surgery:
CXR
CT abd/pelvis
MRI brain if extensive disease
If CT is positive, then order bone scan

Labs: CBC, CMP, AFP, BHCG, LDH

Counseling: Fertility assessment with semen analysis, consideration of sperm banking

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6
Q

Half life of AFP and b-hcg?

A

AFP: 5-7 days
bHCG: 1-2 days

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7
Q

First echelon nodes

A

Left testicle: Nodes just below the left renal hilum

Right testicle: Follows path to IVC, so nodes drain to paracaval and interaortocaval nodes

If scotal invasion: inguinal nodes

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8
Q

Type of surgery needed?

A

Inguinal orchiectomy with high ligation of the spermatic cord

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9
Q

Poor prognostic factors for seminoma

A

Rete testes invasion
LVSI
Size > 5 cm

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10
Q

Treatment Options for Stage I

A

RT
Observation
Carboplatin x 1 cycle (AUC 7)

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11
Q

T Staging

A

T1: testis/epididymis
T2: +LVI or invasion into tunica vaginalis
T3: spermatic cord
T4: scrotum

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12
Q

N Staging

A

N1: 2 cm or less and 5 LNs or less
N2: > 2 cm and/or more than 5 LNs or ECE
N3: > 5 cm

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13
Q

M Staging

A

M1a: non-regional nodes or pulmonary mets
M1b: other mets

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14
Q

Contraindications to observation?

A

Major: size > 4 cm, rete testis invasion
Minor: LVSI, age < 34

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15
Q

Field Borders for Stage I

A

Paraaortic field only

Top: T10-T11
Bottom: L5-S1
Lat: Transverse processes, if left side give 1 cm border to include left renal hilum and SI joint

Block kidneys

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16
Q

Field borders for Stage IIA-IIB

A

Top: T10-T11
Bottom: Midobturator foramen

Lateral ipsilateral: renal hilum down to the L5-1S1 then diagnonally to lateral edge of acetabulum and then down to midobturator

Contralateral: inclusion of the transverse process down to L5-S1, then diagonally in parallel with ipsilateral border, then vertically to median border of obturator foramen

2 cm on all nodes

Block kidneys

Goal is to cover ipsilateral common iliac, external iliac and internal iliac.

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17
Q

Acute side effects of RT

A

N/V
Decreased blood counts
Diarrhea

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18
Q

Late side effects of RT

A

Chronic diarrhea
Duodenal ulcer
SBO
Oligo or azospermia

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19
Q

What dose causes sterilization?

A

2 Gy

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20
Q

What dose causes total azospermia with eventual recovery?

A

1 Gy with recovery in 1-2 years

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21
Q

What dose causes transient azospermia?

A

20-50 cGy with recovery at 1 year

22
Q

Follow up after RT for Stage I

A

Palpate contralateral testicle, left SCL, labs including AFP, HCG, LDH and CXR every 3 months for 1 year

For year 2-3, move to every 6 months

A pelvic CT is needed annually for 3 years for PA-RT only

23
Q

What is the relapse rate for patients without risk factors and Stage I disease with observation?

A

15%

12% PA
3% pelvis

24
Q

What are the side effects of carboplatin?

A

Hair loss
Myelosuppression
Ototoxicity
Renal toxicity

25
Q

What is the treatment for Stage IIC-III?

A

BEP for 3-4 cycles and if CR then observe, if residual masses then surgery or RT

26
Q

CT simulation

A

CT Abdomen/Pelvis
IV contrast
Clamshell on uninvolved testis
Position penis out of field

27
Q

5 year DFS after tx for Stage IIC-III?

A

Stage IIC-III: 85-90%

28
Q

What is BEP?

A

Bleomycin
Etoposide
Cisplatin

29
Q

Do seminomas have elevated AFP?

A

No

30
Q

What percentage of testicular germ cell tumors are seminomas?

A

60% are pure seminomas
30% are non-seminomatous germ cell tumors
10% are mixed

31
Q

What is the most common age group?

A

25-40 years old

32
Q

What is the risk of contralateral seminoma after treatment of one sided disease?

A

3.6% over 25 years

33
Q

What are the layers of the testis to scrotum going from inside to out?

A
  1. Tunica albuginea
  2. Visceral layer of tunica vaginalis
  3. Parietal layer of tunica vaginalis
  4. Internal spermatic fascia
  5. Cremaster muscle
  6. External spermatic fascia
  7. Tunica dartos
  8. Skin
34
Q

What factors increase the risk for pelvic nodal disease?

A
  1. Prior scrotal or inguinal surgery
  2. Tumor invasion of the tunica vaginalis or lower one third of the epididymis
  3. Cryptorchidism
35
Q

How often is bHCG elevated with seminomas?

A

15%

36
Q

What percentage of patients have Stage I disease? Stage II disease?

A

Stage I: 70-80%

Stage II: 15-20%

37
Q

Post-op treatment for Stage IIA

A

Paraortic RT: 25.5 at 1.5 Gy/fx

38
Q

What are treatment options for relapse after observation?

A

Retroperitoneal RT for nodes < 5 cm or chemotherapy

39
Q

What is the relapse rate after PA RT?

A

0.5 to 5% and most recurrences occur within 2 years

40
Q

What are contraindications to RT?

A
  1. Horseshoe kidney
  2. Prior radiation
  3. IBD
41
Q

Where do patients recur after paraaortic RT?

A
  1. Mediastinum
  2. Left SCL
  3. Pelvis
42
Q

What subtype of seminoma can be treated with orchiectomy alone?

A

Spermatocytic seminoma

43
Q

Stage I disease

A

T1-4 N0 M0 S1-3

44
Q

Stage II

A

S0-1

IIA: N1
IIB: N2
IIC: N3

45
Q

Stage III

A

S2-3 with N1-N3 or M1

46
Q

How to assign S designation?

A

Labs done prior to surgery:

S1: LDH < 1.5 times normal, bHCG < 5000, AFP < 1000
S2: LDH 1.5-10 times normal, bHCG 5K to 50K, or AFP 1K-10K
S3: LDH > 10 times normal, bHCG > 50 K, AFP >1K

47
Q

RT acute complications

A

Nausea
Diarrhea
Lethargy

48
Q

RT late complications

A 
Infertility (30% of patients can have children after)
Peptic ulcer disease
Small bowel obstruction 
Second cancers (5-10% increase in risk)
Chronic diarrhea
49
Q

How much does clamshell protect testicle?

A

It reduces dose to remaining testicle by 2-3

50
Q

What dose do you treat Stage IIA or IIB disease?

A

IIA: Initial field to 25.5 Gy at 1.5 Gy/fx then boost 4.5 Gy at 1.5 Gy/fx to nodes plus 2 cm margin

IIB: Initial field to 25.5 Gy at 1.5 Gy/fx then boost 10.5 Gy at 1.5 Gy/fx to nodes plus 2 cm margin

51
Q

Follow up after RT for stage II?

A

Palpate contralateral testicle, left SCL, labs including AFP, HCG, LDH and CXR every 3 months for 3 years

For year 3-4, move to every 6 months

A pelvic CT is needed annually for 3 years for PA-RT only

52
Q

Kidney constraint

A

V20 < 70%

Testicular Cancer (1 decks)

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